This area is only available to WorkCompResearch subscribers. WCR offers the most advanced Compliance and Regulatory Research System available.

Already a member? Log-in

Join Today for Immediate Access!


Sign Up


Home| Forms| Legal Library| Compliance| Calculators| State Comparisons| Reference Desk| What's New| Roundtable
Pre-select A State ↓ (Optional)   Current State: None   (← what's this?)

Longshore Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
If you do not have Adobe Acrobat Reader, you may download it here for free. Download Adobe Here

All of these forms may now be auto-populated from your claims software program! Click here to learn about FlashForm SSL.


Form

Description

ls-202.pdf Employers First Report of Injury or Occupational Illness
ls-1.pdf Request for Examination and/or Treatment
ls-18.pdf Pre-Hearing Statement
ls-33.pdf Approval of Compromise of Third Person Cause of Action
ls-200.pdf Report of Earnings
ls-201.pdf Notice of Employee's Injury or Death
ls-203.pdf Employee's Claim for Compensation
ls-204.pdf Attending Physician's Supplementary Report
ls-206.pdf Payment of Compensation without Award
ls-207.pdf Notice of Controversion of Right to Compensation
ls-208.pdf Notice of Final Payment or Suspension of Compensation Payments
ls-210.pdf Employer's Supplementary Report of Accident or Occupational Illness
ls-262.pdf Claim for Death Benefits
ls-265.pdf Certification of Funeral Expenses
ls-266.pdf Application for Continuation of Death Benefit for Student
ls-267.pdf Claimant's Statement
ls-271.pdf Application for Self-Insurance
ls-272.pdf Application to Write Longshore Insurance
ls-274.pdf Report of Injury Experience of Insurance Carrier or Self-Insured Employer
ls-275ic.pdf Agreement and Undertaking (Insurance Carrier)
ls-275si.pdf Agreement and Undertaking (Self-Insured Employer)
ls-276.pdf Application for Security Deposit Determination
ls-426.pdf Request for Earnings Information
ls-513.pdf Report of Payments
ls-570.pdf Carrier's Report of Issuance of Policy
ls-801.pdf Waiver of Service by Registered or Certified Mail for Employers and/or Insurance Carriers
ls-802.pdf Waiver of Service by Registered or Certified Mail for Claimants and Authorized Representatives
owcp-5a.pdf Work Capacity Evaluation Psychiatric/Psychological Conditions
owcp-5b.pdf Work Capacity Evaluation Cardiovascular/Pulmonary Conditions
owcp-5c.pdf Work Capacity Evaluation for Musculoskeletal Conditions
owcp-16.pdf Rehabilitation Plan and Award
owcp-17.pdf Rehabilitation Maintenance Certificate
owcp-44.pdf Rehabilitation Action Report
ls-241-242.pdf Notice to Employees (Longshore) - Not currently available online. To inquire about this form please contact the Longshore National Office. (202) 693-0038
DBANoticetoEmployees.pdf Notice to Employees (Defense Base Act)